The Scapula: The Greater Masquerader of Shoulder Pathologies.

A comprehensive review of scapular pathologies and their effect on shoulder function is necessary to determine the best treatment options. The coordinated motion between the scapulothoracic and glenohumeral joints is essential for shoulder motion and depends on the balanced activity of the periscapular muscles. Disruption in these muscles can cause abnormal scapular motion and compensatory glenohumeral movements, leading to misdiagnosis or delayed diagnosis. Scapular pathologies can arise from muscle overactivity or underactivity/paralysis, resulting in a range of scapulothoracic abnormal motion (STAM). STAM can lead to various glenohumeral pathologies, including instability, impingement, or nerve compression. It is important to highlight the critical periscapular muscles involved in scapulohumeral rhythm (such as the upper, middle, and lower trapezius; rhomboid major and minor; serratus anterior; levator scapulae; and pectoralis minor). A discussion of the different etiologies of STAM should include examples of muscle dysfunction, such as overactivity of the pectoralis minor, underactivity or paralysis of the serratus anterior or trapezius muscles, and dyskinesis resulting from compensatory mechanisms in patients with recurrent glenohumeral instability due to Ehlers-Danlos syndrome. The evaluation and workup of STAM has shown that patients typically present with radiating shoulder pain, especially in the posterior aspect of the shoulder and scapula, and limitations in active shoulder overhead motion associated with glenohumeral pain, instability, or rotator cuff pathologies.

Scapular Dyskinesia: How to Differentiate Between Etiologies.

It is important to discuss the importance of synchronous balance between periscapular muscles for scapulothoracic motion and resultant scapulohumeral rhythm. Abnormalities in this balance can lead to scapular dyskinesia and winging, affecting shoulder motion and leading to impingement. Strategies exist to diagnose and differentiate between pathologies such as muscle paralysis (eg, trapezius or serratus anterior) or overactivity (eg, pectoralis minor). The physician should be aware of the role of diagnostic imaging, as well as the unique considerations for patients with Ehlers-Danlos syndrome. Overall, a comprehensive physical examination to accurately diagnose and treat scapular pathologies is particularly important.

A Changing Landscape in the Surgical Management of Wrist Arthritis: An Analysis of National Trends From 2009 to 2019.

PURPOSE: The purpose of this study was to analyze the trends in the annual volume and incidence of proximal row carpectomy (PRC), four-corner fusion (4CF), total wrist arthrodesis (TWF), and total wrist arthroplasty (TWA) from 2009 to 2019 in the United States. METHODS: The IBM Watson Health MarketScan databases were queried to identify annual case volumes for PRC, 4CF, TWF, and TWA from 2009 to 2019. The annual incidence of these procedures was then calculated based on the population estimates from the US Census Bureau. Trends in annual volume and incidence over the study period were evaluated using regression line analysis. Further subgroup analysis was conducted based on age and region. RESULTS: From 2009 to 2019, the total case volumes for the four procedures increased by 3.4%, but the incidence decreased by 2.8%. However, PRC case volume and incidence trends significantly increased (38.2% and 29.7%, respectively), whereas 4CF remained constant. Conversely, the case volume and incidence of TWA significantly decreased (-52.2% and -54.5%, respectively), whereas TWF remained constant. When stratified by age, all four procedures decreased in the <45-year-old cohort (combined -35.1%) significantly for 4CF, TWF, and TWA. TWA decreased significantly in the <45-year-old and 45- to 65-year-old cohorts (53.6% and 63.2%, respectively). For age >65 years, the total case incidence increased by 98.9%, including a significant positive trend in TWF (175%). CONCLUSIONS: Surgical management of wrist arthritis remains a controversial issue. However, PRC has gained recent support in the literature, and our results reflect this shift, even for the <45-year-old cohort. Furthermore, TWA declined, despite reports of positive early outcomes for fourth-generation implants. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Methylprednisolone taper is an effective addition to multimodal pain regimens after total shoulder arthroplasty: results of a randomized controlled trial: 2022 Neer Award winner.

BACKGROUND: Perioperative corticosteroids have shown potential as nonopioid analgesic adjuncts for various orthopedic pathologies, but there is a lack of research on their use in the postoperative setting after total shoulder arthroplasty (TSA). The purpose of this study was to assess the effect of a methylprednisolone taper on a multimodal pain regimen after TSA. METHODS: This study was a randomized controlled trial (clinicaltrials.gov NCT03661645) of opioid-naive patients undergoing TSA. Patients were randomly assigned to receive intraoperative dexamethasone only (control group) or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course (treatment group). All patients received the same standardized perioperative pain management protocol. Standardized pain journal entries were used to record visual analog pain scores (VAS-pain), VAS-nausea scores, and quantity of opioid tablet consumption during the first 7 postoperative days (POD). Patients were followed for at least one year postoperatively for clinical evaluation, collection of patient-reported outcomes, and observation of complications. RESULTS: A total of 67 patients were enrolled in the study; 32 in the control group and 35 in the treatment group. The groups had similar demographics and comorbidities. The treatment group demonstrated a reduction in mean VAS pain scores over the first 7 POD. Between POD 1 and POD 7, patients in the control group consumed an average of 17.6 oxycodone tablets while those in the treatment group consumed an average of 5.5 tablets. This equated to oral morphine equivalents of 132.1 and 41.1 for the control and treatment groups, respectively. There were fewer opioid-related side effects during the first postoperative week in the treatment group. The treatment group reported improved VAS pain scores at 2-week, 6-week, and 12-week postoperatively. There were no differences in Europe Quality of Life, shoulder subjective value (SSV), at any time point between groups, although American Shoulder and Elbow Surgeons questionnaire scores showed a slight improvement at 6-weeks in the treatment group. At mean follow-up, (control group: 23.4 months; treatment group:19.4 months), there was 1 infection in the control group and 1 postoperative cubital tunnel syndrome in the treatment group. No other complications were reported. CONCLUSIONS: A methylprednisolone taper course shows promise in reducing acute pain and opioid consumption as part of a multimodal regimen following TSA. As a result of this study, we have included this 6-day methylprednisolone taper course in our multimodal regimen for all primary shoulder arthroplasties. We hope this trial serves as a foundation for future studies on the use of low-dose oral corticosteroids and other nonnarcotic modalities to control pain after shoulder surgeries.

Trends in Costs and Professional Reimbursements for Revision Total Hip and Knee Arthroplasty.

BACKGROUND: With increasing numbers of revision total hip and total knee arthroplasties (rTHAs and rTKAs), understanding trends in related out-of-pocket (OOP) costs, overall costs, and provider reimbursements is critical to improve patient access to care. METHODS: A large database was used to identify 92,116 patients who underwent rTHA or rTKA between 2009 and 2018. The OOP costs associated with the surgery and related inpatient care were calculated as the sum of copayment, coinsurance, and deductible payments. Professional reimbursement was calculated as total payments to the principal physician. All monetary data were adjusted to 2018 dollars. Multivariate regressions evaluated the associations between costs and procedure type, insurance type, and region of service. RESULTS: From 2009 to 2018, overall costs for rTHA significantly increased by 35.0% and overall costs for rTKA significantly increased by 32.3%. The OOP costs for rTHA had no significant changes, while OOP costs for rTKA increased by 20.1%, with patients on Medicare plans having the lowest OOP costs. Professional reimbursements, when measured as a percentage of overall costs, decreased significantly by 4.4% for rTHA and 4.0% for rTKA, with the lowest reimbursements from Medicare plans. CONCLUSION: From 2009 to 2018, total costs related to rTHA and rTKA significantly increased. The OOP costs significantly increased for rTKA, and professional reimbursements for both rTHA and rTKA decreased relative to total costs. Overall, these trends may combine to create greater financial burden to patients and the healthcare system, as well as further limit patients' access to revision arthroplasty care.

Chronic Anticoagulation is Associated With Increased Risk for Postoperative Complications Following Aseptic Revision Total Hip Arthroplasty.

BACKGROUND: With an aging global population, the incidence of revision total hip arthroplasty (rTHA) is expected to increase markedly. While patients undergoing primary total hip arthroplasty who require chronic anticoagulation (AC) have been associated with increased postoperative complications, less is known about the impact of chronic AC status on postoperative complications in the rTHA setting. This study sought to compare complication rates following aseptic rTHA between patients who were on chronic AC and those who were not. METHODS: A large national database was utilized to retrospectively identify 9,421 patients who underwent aseptic rTHA between 2014 and 2019. Patients were divided into 2 cohorts: 1,790 patients (19.0%) were in the chronic AC cohort (ie, having an AC prescription filled within 6 months prior to and following rTHA), and 7,631 patients (81.0%) were not on chronic AC. Postoperative complications at 90-days and 2-years were compared between cohorts utilizing univariate and multivariate analyses, controlling for sex, age, and comorbidities. RESULTS: At 90-days, chronic AC patients had increased odds of prosthetic joint infections (PJIs) (odds ratio [OR] 3.2, P < .001), surgical site infections (OR 3.6, P < .001), and mechanical prosthetic complications (OR 3.5, P < .001), which included any aseptic loosening, implant dislocation, or broken prosthetic. At 2-years, chronic AC patients had increased odds of PJI (OR 3.3, P < .001) as well as mechanical prosthetic complications (OR 3.2, P < .001). Chronic AC patients were also at increased risk for reoperation within 2 years after initial aseptic rTHA (OR 1.9, P < .001). CONCLUSIONS: Patients on chronic AC have significantly higher odds of 90-day and 2-year complications after aseptic rTHA. This includes increased odds of PJI, surgical site infection, and mechanical prosthetic complications. Patients receiving chronic AC who undergo rTHA should be counseled on the risk-benefit ratio of their chronic AC status in a multidisciplinary setting to optimize their postoperative outcomes.

Should All Patients Receive Extended Oral Antibiotic Prophylaxis? Defining Its Role in Patients Undergoing Primary and Aseptic Revision Total Joint Arthroplasty.

BACKGROUND: Prior studies have demonstrated reduced periprosthetic joint infection (PJI) rates following extended oral antibiotics (EOAs) for high-risk patients undergoing primary total joint arthroplasty (TJA). This study compared 3-month PJI rates in all patients undergoing primary or aseptic revision TJA with or without EOA prophylaxis. METHODS: In total, 2,982 consecutive primary (n = 2,677) and aseptic revision (n = 305) TJAs were performed by a single, fellowship-trained arthroplasty surgeon from 2016 to 2022 were retrospectively reviewed. Beginning January 2020, all patients received 7 days of 300 mg oral cefdinir twice daily immediately postoperatively. Rates of PJI at 3 months were compared between patients who received or did not receive EOA. RESULTS: Rates of PJI at 3 months in patients undergoing primary and aseptic revision TJA were significantly lower in those receiving EOA prophylaxis compared to those who did not (0.41 versus 1.13%, respectively; P = .02). After primary TJA, lower PJI rates were observed with EOA prophylaxis utilization (0.23 versus 0.74%, P = .04; odds ratio [OR] 3.85). Following aseptic revision TJA, PJI rates trended toward a significant decrease with the EOA compared to without (1.88 versus 4.83%, respectively; P = .16; OR 2.71). CONCLUSIONS: All patients undergoing primary or aseptic revision TJA who received EOA prophylaxis were 3.85 and 2.71 times less likely, respectively, to develop PJI at 3 months compared to those without EOA. Future studies are needed to determine if these results are maintained at postoperative time periods beyond 3 months following primary TJA. LEVEL OF EVIDENCE: III, Retrospective review.

Dupuytren Disease: Surgical Tips, Optimizing Outcomes, and Cost Considerations.

Dupuytren disease is associated with benign fibroproliferative changes to the palmar fascia of the hand sometimes resulting in progressive contractures of the fingers. The earliest descriptions of these contractures date back to the 18th century. Much has been learned about the condition since the clawing condition was first described; however, optimal treatment still poses significant challenges to modern-day surgeons. It is important to examine the treatment options for Dupuytren disease and highlight the current evidence, techniques, and cost considerations of open fasciectomy, needle aponeurotomy, and recently described minimally invasive treatment.

Variation in scapulohumeral rhythm on dynamic radiography in pathologic shoulders: a novel diagnostic tool.

HYPOTHESIS: The purpose of this study was to analyze the SHR of patients diagnosed with small (SRCTs) and massive rotator cuff tears (MRCTs), adhesive capsulitis (AC), and glenohumeral osteoarthritis (GH-OA) and compare their measurements to those of patient controls with healthy shoulders using DDR. We hypothesize that various diagnoses will vary with regards to SHR. METHODS: The sequences of pulsed radiographs collated in DDR to create a moving image were prospectively analyzed during humeral abduction in normal controls and in 4 distinct shoulder pathology groups: SRCT, MRCT, AC, and GH-OA. GH and ST joint angles were measured at 0°-30°, 30°-60°, 60°-90°, and maximal coronal plane humeral abduction. SHR was defined as the ratio of the change in humeral abduction over the change in scapula upward rotation during humeral abduction and was calculated within the above angle intervals. RESULTS: A total of 121 shoulders were analyzed. Forty normal controls were compared to 13 SRCTs, 29 MRCTs, 16 AC, and 23 GH-OA. SHR during humeral abduction differed significantly in patients with MRCT (1.91 ± 0.72), AC (1.55 ± 0.37), and GH-OA (2.31 ± 1.01) compared to controls (3.39 ± 0.79). When analyzed across 30° intervals of abduction, there was a significantly lower SHR found at 0°-30°, 30°-60°, and 60°-90° in MRCT, AC, and GH-OA across each motion range compared to controls. Control patients had an arc of abduction of 103° ± 32°, which was significantly larger than all other pathologies (MRCT: 76° ± 23°, SRCT: 81° ± 21°, AC: 65° ± 27°, GH-OA: 71° ± 35°) and an average scapular abduction of 33° ± 14°, which was significantly less than patients with an MRCT (46° ± 10°) and AC (65° ± 27°). CONCLUSION: SHR remained significantly lower throughout shoulder abduction in MRCT (43.65%), AC (-54.29%), and GH-OA (32.01%) compared to controls. When isolating for humeral and scapular motion, all 4 pathologies had decreased GH abduction, whereas AC and MRCT had an increased scapular compensatory motion compared to controls. Quantifying kinematic patterns like SHR using DDR can be implemented as a novel, safe, and cost-effective method to diagnose shoulder pathology and to monitor response to treatment.

Medicaid payer status is associated with increased 90-day morbidity and resource utilization following primary shoulder arthroplasty: a propensity score-matched analysis.

BACKGROUND: Medicaid payer status has been shown to affect risk-adjusted patient outcomes and health care utilization across multiple medical specialties and orthopedic procedures. However, there is a paucity of data regarding the impact of Medicaid payer status on 90-day morbidity and resource utilization following primary shoulder arthroplasty (reverse total shoulder arthroplasty [rTSA], anatomic total shoulder arthroplasty [aTSA], and hemiarthroplasty [HA]). The purpose of this study was to examine 90-day readmission and reoperation rates, hospital length of stay (LOS), and direct cost following primary shoulder arthroplasty in the Medicaid population. METHODS: The National Readmission Database was queried for all patients undergoing primary aTSA, rTSA, and HA from 2011 to 2016. Medicaid or non-Medicaid payer status was determined. Patient demographic characteristics and comorbidities, along with 90-day readmission, 90-day reoperation, LOS, and inflation-adjusted cost, were queried. Propensity score matching was used to control for baseline differences in cohorts that could be acting as confounders in the exposure-outcome relationship. This was achieved with 1-to-1 propensity score matching between Medicaid and non-Medicaid patients. Odds ratios (ORs) and 95% confidence intervals (CIs) for 90-day readmission and reoperation rates were calculated, and a comparison of LOS and cost was performed between the propensity score-matched cohorts. RESULTS: A total of 4667 Medicaid and 161,147 non-Medicaid patients were identified from the 2011-2016 National Readmission Databases. Propensity score analysis was performed, and 4637 Medicaid patients were matched to 4637 non-Medicaid patients; each group comprised 1504 rTSAs (32.4%), 1934 aTSAs (41.7%), and 1199 HAs (25.9%). Patients with Medicaid payer status yielded significant increases in the 90-day all-cause readmission rate of 11.6% vs. 9.3% (P < .001; OR, 1.28 [95% CI, 1.12-1.46]), 90-day shoulder-related readmission rate of 3.3% vs. 2.3% (P = .004; OR, 1.44 [95% CI, 1.12-1.85]), and 90-day reoperation rate of 2.0% vs. 1.3% (P = .008; OR, 1.54 [95% CI, 1.12-1.94]). Furthermore, there was an increased risk of an extended LOS (ie, LOS > 2 days) (28.4% vs. 25.7%; P = .004; OR, 1.14 [95% CI, 1.04-1.25]) along with increased direct cost (median, $17,612 vs. $16,775; P < .001). DISCUSSION: This study demonstrates that Medicaid payer status is independently associated with increased 90-day readmission and reoperation rates, LOS, and direct cost following primary shoulder arthroplasty. Providers may have a disincentive to treat patient populations who require increased resource utilization following surgery. Risk adjustment models accounting for Medicaid payer status will be necessary to ensure good access to care for this patient population by avoiding penalties for physicians and hospital systems.

Outcomes of Functioning Free Gracilis Muscle Transplantation to Restore Elbow Flexion in Late Brachial Plexus Birth Injury.

BACKGROUND: Restoring elbow function is challenging after late presenting brachial plexus birth injury (BPBI). Free functioning muscle transplantation (FFMT) using the gracilis muscle is a reliable procedure to restore elbow flexion in patients with impaired function after spontaneous recovery or failed surgical reconstruction. METHODS: A retrospective review was performed on BPBI patients more than 2 years of age who received a FFMT between January 1993 and January 2018, with the aim of improving elbow flexion as the primary or secondary functional goal. Patients with preoperative elbow flexion Medical Research Council (MRC) grades less than 3 with more than or equal to 18 months of follow-up duration were included in the analysis. Patient demographic information and pre/postoperative clinical parameters including elbow flexion MRC scale, passive elbow range of motion, and complications were recorded. Surgical data including donor nerve choice, site of the FFMT tendon attachment, and necessity of concomitant procedures or reoperation were also analyzed. RESULTS: Fifty-six FFMTs were performed for the primary (29 patients) or secondary (26 patients) objective of restoring elbow flexion. The mean age at the time of the procedure was 9.6 years (standard deviation [SD] = 6.29, R = 3-35). Mean follow-up was 7.9 years (SD = 5.2). Elbow flexion improved from a median MRC grade 2 to 4 after a FFMT (p < 0.05). Patients who had a FFMT to restore two functions had 86% lower elbow flexion MRC grades than those who had a FFMT to restore flexion only (p < 0.05). Patients less than 12 years old at the time of surgery had more complications, reoperations, and rates of a flexion contracture more than or equal to 30 degrees than those aged more than 12 years (p < 0.05). CONCLUSION: FFMT is a reliable option for upper extremity reanimation. Patients aged less than 12 years old at the time of FFMT had significantly more complications, reoperations, and rates of postoperative elbow flexion contracture more than or equal to 30 degrees, but equivalent elbow flexion MRC grades. LEVEL OF EVIDENCE: III.

Upper extremity firearm injuries: epidemiology and factors predicting hospital admission.

INTRODUCTION: Civilian gun violence is a public health crisis in the USA that will be an economic burden reported to be as high as $17.7 billion with over half coming from US taxpayers dollars through Medicaid-related costs. The purpose of this study is to review the epidemiology of upper extremity firearm injuries in the USA and the associated injury burden. METHODS: The Inter-university Consortium for Political and Social Research's Firearm Injury Surveillance Study database, collected from the National Electronic Injury Surveillance System, was queried from 1993 to 2015. The following variables were reviewed: patient demographics, date of injury, diagnosis, injury location, firearm type (if provided), incident classification, and a descriptive narrative of the incident. We performed chi-square testing and complex descriptive statistics, and binomial logistic regression model to predict factors associated with hospital admission. RESULTS: From 1993 to 2015, an estimated 314,369 (95% CI: 291,528-337,750; 16,883 unweighted) nonfatal firearm upper extremity injuries with an average incidence rate of 4.76 per 100,000 persons (SD: 0.9; 03.77-7.49) occurred. The demographics most afflicted with nonfatal gunshot wound injuries were black adolescent and young adult males (ages 15-24 years). Young adults aged 25-34 were the second largest estimate of injuries by age group. Hands were the most commonly injured upper extremity, (55,014; 95% CI: 75,973-89,667) followed by the shoulder, forearm, and upper arm. Patients who underwent amputation (OR: 28.65; 95% CI: 24.85-33.03) or with fractures (OR: 26.20; 95% CI: 23.27-29.50) experienced an increased likelihood for hospitalization. Patients with a shoulder injury were 5.5× more likely to be hospitalized than those with a finger injury (OR:5.57; 95% CI:5.35-5.80). The incidence of upper extremity firearm injuries has remained steady over the last decade ranging between 4 and 5 injuries per 100,000 persons. Patients with proximal injuries or injuries involving the bone were more likely to require hospital admission. This study should bring new information to the forefront for policy makers regarding gun violence.

The effect of ASA, ticagrelor, and heparin in ST-segment myocardial infarction patients with prolonged transport times to primary percutaneous intervention.

OBJECTIVES: To investigate the effects of early upstream antithrombotic therapy administration (ATTA) in ST-segment elevation myocardial infarction (STEMI) patients with prolonged transport times to primary percutaneous intervention (PPCI) on major clinical outcomes. BACKGROUND: It remains unclear whether early upstream administration of aspirin, ticagrelor, and unfractionated heparin (UFH) confers additional benefits compared with in-hospital administration. METHODS: Between 2015 and 2018, we performed PPCI in 709 included consecutive STEMI patients. We compared 482 STEMI patients who received aspirin, ticagrelor, and UFH loading in a non-PCI capable spoke hospital before transfer (NPHT) versus 227 prehospital triage setting (PTS) STEMI patients who received in-ambulance aspirin, followed by ticagrelor and UFH in the hub catheterization laboratory. The primary outcome was the presence of a pre-PPCI TIMI flow 2-3 in the infarct related artery (IRA). The secondary outcomes included definite acute stent thrombosis and hemorrhagic complications. RESULTS: The median times from ticagrelor and heparin administration to angiography in the NPHT group and the PTS group were 80.5 min (Interquartile Range (IQR) 68.5-94) and 10 min (IQR 5-15) respectively (p < .0001). Using inverse probability of treatment weighting to minimize heterogeneity between groups, we showed significant differences for the primary outcome (44.6 versus 18.5%, p < .0001) and for definite acute stent thrombosis (0.6 versus 2.6%, p = .03), with no difference in the combined in-hospital BARC 2-5 bleeding events (1.9 versus 3.5%, p = .18) in the NPHT versus the PTS group, respectively. CONCLUSION: In this single-center retrospective cohort study, after adjusting for baseline covariates, early upstream ATTA with aspirin, ticagrelor, and UFH was associated with greater pre-PPCI TIMI flow and less definite acute stent thrombosis in STEMI patients, without increased bleeding risk.

The surgical treatment of proximal humerus fractures 2010-2019: United States national case volume and incidence trends.

Background: Proximal humerus fractures are the third most common fracture type for patients between the ages of 65 and 89 and occur more frequently in women than men. Given the variety of surgical treatments for proximal humerus fractures, the aim of this study was to (1) report United States national volume and incidence estimates for surgical management of proximal humerus fractures to better understand the changing practice over the past decade and (2) to analyze differences in volume and incidence among age groups, sex, and geographic region. Methods: Using IBM Marketscan national database, all patients that underwent open reduction internal fixation (ORIF), hemiarthroplasty, or reverse total shoulder arthroplasty (RTSA) between 2010 and 2019 were identified with Current Procedural Terminology codes. The dataset was further stratified to identify patients treated for proximal humerus fractures. IBM Marketscan provided discharge weights that were used to determine estimated national annual volumes of each procedure in IBM SPSS Statistics software (IBM Corp., Armonk, NY, USA). Volume and incidence were adjusted per 1,000,000 persons and calculated for subgroups according to age group, sex, and geographical region. The United States Census Bureau annual population data was used for all incidence calculations. Results: Over the past decade, the total volume and incidence of surgically treated proximal humerus fractures increased by 13% and 5%, respectively. Although overall incidence decreased, ORIF remained the most common surgical treatment. The greatest decrease in volume and incidence of ORIF occurred in patients ≥75. The incidence of ORIF treatment increased in the South and West while it decreased in the Northeast and Midwest. Total volume and incidence of HA decreased between 2010 and 2019 and this trend remained among all subgroups. Total volume and incidence of RTSA increased by over 300%. The incidence of males and females receiving RTSA increased by 266% and 320%, respectively. Volume and incidence of RTSA increased across all age groups. Volume and incidence of RTSA increased in the Midwest, South, and Western regions while it remained unchanged in the Northeast. Conclusion: Surgical management trends of proximal humerus fractures have changed greatly over the past decade. ORIF remains the most common surgical treatment for proximal humerus fractures. HA has fallen out of favor while RTSA has seen significant increases in usage across sex, age groups, and geographic regions. These trends represent a change in practice for treating proximal humerus fractures by considering all patient and fracture characteristics when opting for surgical management.

Database analysis comparing incidence and complication rates between inpatient and outpatient laminotomies for lumbar disc herniation.

Background: Lumbar disc herniation (LDH) is a common condition that can be characterized with disabling pain. While most patients recover without surgery, some still require operative intervention. The epidemiology and trends of laminotomy for LDH have not been recently studied, and current practice patterns might be different from historical norms. This study aimed to investigate the trends of inpatient and outpatient laminotomies for LDH and compare complication rates between these two sites of service. Methods: A large, national database was utilized to identify patients > 8 years old who underwent a laminotomy for LDH between 2009 and 2019. Two cohorts were created based on site of surgery: inpatient versus outpatient. The outpatient cohort was defined as patients who had a length of stay less than 1 day without any associated hospitalization. Epidemiologic analyses for these cohorts were performed by demographics. Patients in both groups were then 1:1 propensity-score matched based on age, sex, insurance type, geographic region, and comorbidities. Ninety-day postoperative complications were compared between cohorts utilizing multivariate logistic regressions. Results: The average incidence of laminotomy for LDH was 13.0 per 10,000 persons-years. Although the national trend in incidence had not changed from 2009 to 2019, the proportion of outpatient laminotomies significantly increased in this time period (p=.02). Outpatient laminotomies were more common among younger and healthier patients. Patients with inpatient laminotomies had significantly higher rates of surgical site infections (odds ratio [OR] 1.61, p<.001), venous thromboembolism (VTE) (OR 1.96, p<.001), hematoma (OR 1.71, p<.001), urinary tract infections (OR 1.41, p<.001), and acute kidney injuries (OR 1.75, p=.001), even when controlling for selected confounders. Conclusions: Our study demonstrated an increasing trend in the performance of laminotomy for LDH toward the outpatient setting. Even when controlling for certain confounders, patients requiring inpatient procedures had higher rates of postoperative complications. This study highlights the importance of carefully evaluating the advantages and disadvantages of performing these procedures in an outpatient versus inpatient setting.

Upper Extremity Fractures in the Emergency Department: A Database Analysis of National Trends in the United States.

BACKGROUND: Upper extremity (UE) fractures are a common reason for emergency department (ED) visits, but recent data on their epidemiology are lacking. This study aimed to describe the incidence, demographics, patient characteristics, and associated health care factors of UE fractures, hypothesizing that they would remain prevalent in the ED setting. METHODS: Using the Nationwide ED Sample database, patients presenting to the ED with UE fractures in 2016 were identified, and population estimates were used to calculate incidence rates. Data on insurance status, trauma designation, cost, and teaching status were analyzed. RESULTS: The study identified 2 118 568 patients with UE fractures, representing 1.5% of all ED visits in 2016. Men accounted for 54.2% of UE fractures, with phalangeal fractures being most common. Distal radius and/or ulna fractures were most common in women (30.4%). The greatest proportion of UE fractures (23.2%) occurred in patients aged 5 to 14 years (1195.5 per 100 000). Nontrauma centers were the most common treating institutions (50.4%), followed by level I (19.5%), II (15.3%), and III (12.8%) centers. The greatest proportion of fractures (38.3%) occurred in the southern United States. Emergency department cost of treatment was almost 2-fold in patients with open UE fractures compared with closed. CONCLUSION: This study provides important epidemiological information on UE fractures in 2016. The incidence rate of UE fractures in the ED has remained high, with most occurring in the distal radius, phalanges, and clavicle. In addition, UE fractures were most common in younger patients, men, and those in the southern United States during the summer. These findings can be useful for health care providers and policymakers when evaluating and treating patients with UE fractures.

Novel Diagnostic and Treatment Techniques for Neurogenic Thoracic Outlet Syndrome.

Neurogenic thoracic outlet syndrome is a challenging condition to diagnose and treat, often precipitated by the triad of repetitive overhead activity, pectoralis minor contracture, and scapular dyskinesia. The resultant protracted scapular posture creates gradual repetitive traction injury of the suprascapular nerve via tethering at the suprascapular notch and decreases the volume of the brachial plexus cords and axillary vessels in the retropectoralis minor space. A stepwise and exhaustive diagnostic protocol is essential to exclude alternate pathologies and confirm the diagnosis of this dynamic pathologic process. Ultrasound-guided injections of local anesthetic or botulinum toxin are a key factor in confirming the diagnosis and prognosticating potential response from surgical release. In patients who fail over 6 months of supervised physical therapy aimed at correcting scapular posture and stretching of the pectoralis minor, arthroscopic surgical release is indicated. We present our diagnostic algorithm and technique for arthroscopic suprascapular neurolysis, pectoralis minor release, brachial plexus neurolysis, and infraclavicular thoracic outlet decompression.

Prolonged Opioid Use Following Distal Radius Fracture Fixation: Who Is at Risk and What are the Consequences?

Purpose: Opioid pain medication is most commonly prescribed after distal radius fracture fixation, and there is high variability in the quantity and duration prescribed. Comorbidities, including substance use and depression, have been associated with higher consumption habits, and increased sizes of postoperative opioid prescriptions have been previously linked to an increasing risk of chronic opioid use and opioid use disorder. The purpose of this study was to investigate opioid prescription patterns after distal radius fracture fixation and identify patient-specific risk factors associated with increased opioid prescription refills. Methods: A retrospective review of 34,629 opioid-naïve patients was conducted using the IBM MarketScan database. The database was queried to identify patient records from January 2009 to December 2017. Demographic, comorbidity, complication data, and prescription pharmacy claims were analyzed. Patients were sorted according to the duration of postoperative prescription refills of opioid pain medication. Results: Seventy-three percent of the patients required no additional refills outside the perioperative window. Twenty percent required additional refill prescriptions, and 6.4% of patients continued to fill the opioid medication beyond 6 months after surgery. Multiple factors increased the risk of increased opioid use, including medical and surgical complications, substance use, diabetes, cardiovascular disease, and obesity. Patients with a longer duration of opioid use after surgery had higher rates of medical and surgical complications. Perioperative prescription quantities were 62.9, 78.6, and 83.3 tablets for no refill, refill (<6M), and prolonged-use groups (>6M), respectively. Conclusions: Patients who underwent distal radius fracture fixation were at greater odds for prolonged opioid use after surgery in the presence of comorbid cardiovascular, renal, metabolic, and mental health illnesses and postoperative medical and surgical complications. A greater understanding of patient-specific factors for prolonged opioid consumption after distal radius fracture fixation can help providers identify at-risk patients who would benefit from a tailored approach to counseling and multimodal pain management. Patients should be educated on these risks associated with their surgery and be provided with alternative medical options and health care resources to optimize pain control and reduce their need for opioid medication as their primary tool for pain relief. Type of study/level of evidence: Therapeutic III.

Total Wrist Arthroplasty as a Motion-Sparing Option for Distal Radius Malunion in a Patient of Advanced Age: A Case Report.

CASE: A 62-year-old woman presented with wrist pain secondary to a distal radius fracture malunion 4 months after a fall onto an outstretched hand. She was not an ideal candidate for osteotomy and bone graft because of the degree of displacement and osteoporosis, so after nonoperative treatment was unsuccessful, she was offered total wrist arthroplasty (TWA) or arthrodesis and opted for TWA. CONCLUSION: At 14-month follow-up, the patient reported significant improvement in her pain and function. The current generation of TWA implants may allow use in the management of symptomatic distal radius malunions in older, low-demand patients.

Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique.

Compressive pathology in the supraclavicular and infraclavicular fossae is broadly termed "thoracic outlet syndrome," with the large majority being neurogenic in nature. These are challenging conditions for patients and physicians and require robust knowledge of thoracic outlet anatomy and scapulothoracic kinematics to elucidate neurogenic versus vascular disorders. The combination of repetitive overhead activity and scapular dyskinesia leads to contracture of the scalene muscles, subclavius, and pectoralis minor, creating a chronically distalized and protracted scapular posture. This decreases the volume of the scalene triangle, costoclavicular space, and retropectoralis minor space, with resultant compression of the brachial plexus causing neurogenic thoracic outlet syndrome. This pathologic cascade leading to neurogenic thoracic outlet syndrome is termed pectoralis minor syndrome when primary symptoms localize to the infraclavicular area. Making the correct diagnosis is challenging and requires the combination of complete history, physical examination, advanced imaging, and ultrasound-guided injections. Most patients improve with nonsurgical treatment incorporating pectoralis minor stretching and periscapular and postural retraining. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. In addition to prior exclusively open procedures with supraclavicular, infraclavicular, and/or transaxillary approaches, new minimally invasive and targeted endoscopic techniques have been developed over the past decade. They involve the endoscopic release of the pectoralis minor tendon, with additional suprascapular nerve release, brachial plexus neurolysis, and subclavius and interscalene release depending on the preoperative work-up.